Edd Unemployment Insurance Application

For Department Use Only Date Received: Date Postmarked/Faxed: Effective Date:

UNEMPLOYMENT INSURANCE APPLICATION FILING INSTRUCTIONS Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only. Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay or prevent the filing of your claim, or cause benefits to be denied. If the Department needs to verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide additional information and/or documentation.

APPLICATION QUESTIONS The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a false statement or withhold information. 1. What is your Social Security Number as given to you by the Social Security Administration?

1. a)

a) If EDD assigned you an EDD Client Number (ECN), please provide the ECN here. (An ECN is a 9-digit number beginning with 999.) 2. List any other Social Security Numbers you have used.

2.

3. What is your full name?

3. Last _______________________________________________ First ______________________________________________ Middle Initial ____

4. Is this the name that appears on your Social Security card?

4.

Yes

No

a) Last ___________________________________________

a) If no, provide the name that appears on your Social Security card.

First ___________________________________________ Middle Initial ____

5. List any other names you have used.

5. __________________________________________________ __________________________________________________

6. What is your birth date?

6.

7. What is your gender?

7.

Male

Female

8. Would you prefer your written material in English or Spanish?

8.

English

Spanish

a) ________________________________________

a) What is your preferred spoken language? 9. Have you filed a California Unemployment Insurance or a Disability Insurance claim in the last two years? a) If yes, please list for each type of claim, the most recent date(s) of when the claim(s) was filed.

(mm/dd/yyyy)

9.

Yes

No

Unemployment Claim Date(s) (mm/dd/yyyy)

Disability Claim Date(s) (mm/dd/yyyy)

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UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: 10. Do you have a Driver’s License issued to you by a state/entity?

10.

a) If yes, provide the name of the issuing state/entity and your Driver’s License number.

Yes

-

-

No

a) Name of issuing state/entity: ________________________ Driver’s License Number: __________________________

If no, answer questions b-d:

If no, answer questions b-d:

b) Do you have an Identification Card issued to you by a state/entity?

b)

c) If yes, provide the name of the issuing state/entity and your Identification Card number.

c) Name of issuing state/entity: ________________________ Identification Card Number: _________________________

d) How do you look for work and, if you have work, how do you get to work?

d) Please Explain: __________________________________ _______________________________________________ _______________________________________________

Yes

11. (

11. What is your telephone number? a) If you are deaf, hard of hearing, or have a speech disability and use TTY or California Relay to communicate, check the appropriate box.

No

)

a)

-

TTY (Non Voice)

California Relay Service

12. Street: _______________________________ Apt.

12. What is your mailing address? (Include your city, state, and ZIP code)

City: ______________________________________________ State:

13. Is your residence address the same as your mailing address?

13.

Yes

ZIP Code: No

a) If no, enter your residence address. (Include your city, state, ZIP code and apartment number.) A residence address cannot be a P.O. Box. Please provide a street address.

a) Street: ____________________________ Apt. _______

14. If you do not live in California, what is the name of the County in which you live?

14. __________________________________________________

City: __________________________________________ State:

ZIP Code:

15. What is the highest grade of school you have completed? Check only one box. Did not complete High School

High School Diploma or GED

Some college or vocational school

Associate of Arts

Bachelor of Arts or Science

Masters or Doctorate

16. Are you a Military Veteran?

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16.

Yes

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No

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number:

-

-

17. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer. a) b) c) d) e)

Name(s) of all employers you worked for in the last 18 months. Period of employment (Dates Worked). Total Wages earned for each employer in the last 18 months. How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate). Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution.

NOTE: It is very important that you report the employer name(s), period of employment and wages correctly. Failure to provide complete information will result in your benefits being delayed or denied. a) Employer Name

e) Is this employer a school employer? a) Employer Name

e) Is this employer a school employer? a) Employer Name

e) Is this employer a school employer? a) Employer Name

e) Is this employer a school employer? a) Employer Name

e) Is this employer a school employer? a) Employer Name

e) Is this employer a school employer?

b) Dates Worked From: To: Yes

No

c) Total Earnings $

If yes, provide phone number (

b) Dates Worked From: To: Yes

No

c) Total Earnings $

If yes, provide phone number (

b) Dates Worked From: To: Yes

No

c) Total Earnings $

If yes, provide phone number (

b) Dates Worked From: To: Yes

No

c) Total Earnings $

If yes, provide phone number (

b) Dates Worked From: To: Yes

No

c) Total Earnings $

If yes, provide phone number (

b) Dates Worked From: To: Yes

18. During the past 18 months did you work for any other employers not listed in question 17?

No

c) Total Earnings $

If yes, provide phone number (

18.

Yes

If yes, list the employer name, dates worked, total earnings, and how you were paid on a separate sheet of paper. Attach the additional sheet of paper to this application.

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No

d) How were you paid? _____________________

)

-

d) How were you paid? _____________________

)

-

d) How were you paid? _____________________

)

-

d) How were you paid? _____________________

)

-

d) How were you paid? _____________________

)

-

d) How were you paid? _____________________

)

-

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: 19. Which employer in question 17 did you work for the longest?

-

-

19. Employer name: ____________________________________

a) What type of business was operated by the employer? (Please be specific. For example, restaurant, dry cleaning, construction, book store.)

a) Type of business: _______________________________________________

b) How long did you work for that employer?

b) Years ______ Months _____

c) What type of work did you do for that employer?

c) _______________________________________________

20. What is your usual occupation?

20. __________________________________________________

21. Is your usual work seasonal?

21.

Yes

No

If yes, answer questions a-c:

If yes, answer questions a-c:

a) When does the season usually begin?

a) _______________________________________________

b) When does the season usually end?

b) _______________________________________________

c) What other work related skills do you have?

c) _______________________________________________

Please provide information on your very last employer. This is the employer you last worked for regardless of the length of time you worked at that job, the type of work you did for that employer or whether or not you have been paid. Reminder: To file a claim, individuals must be out of work or working less than full time. You must provide information on the last employer you worked for as an employee. Do not include self-employment unless you have elective coverage. 22. What is the last date you actually worked for your very last employer?

22.

(mm/dd/yyyy)

a) What are your gross wages for your last week of work? For unemployment insurance purposes, a week begins on Sunday and ends the following Saturday.

a) $

b) What is the complete name of your very last employer?

b) Name

c) What is the mailing address of your very last employer?

c) Mailing address: Street: _________________________________________ City: __________________________________________ ZIP Code: State:

d) Is the physical address of your very last employer the same as their mailing address? (A physical address cannot be a P.O. Box. Please provide a street address.)

d)

If no, what is the physical address of your very last employer?

_________________________________________

Yes

No

Physical address: Street: _________________________________________ City: ___________________________________________ State: ZIP Code:

e) What is the telephone number of your very last employer at their physical address?

e) (

f) What is the name of your immediate supervisor?

f)

g) Briefly explain in your own words the reason you are no longer working for your very last employer, within the space provided. Please do not include any attachments.

g) Reason: ________________________________________ _______________________________________________ _______________________________________________ _______________________________________________

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)

-

_______________________________________________

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UNEMPLOYMENT INSURANCE APPLICATION Social Security Number:

-

23. Are you (directly or indirectly) out of work with any employer (last employer or any employer in the last 18 months) due to a trade dispute, such as a strike or a lockout? If yes and a union was/is involved, answer questions a-b: a)

What is the name and telephone number of the union? Name ____________________________________ Phone: ( ) -

b) Are you going to receive strike benefits?

Yes No

24. Are you currently working for or do you expect to work for any school or educational institution or perform school-related work?

Yes

No

If yes and a union was not/is not involved, answer questions c-e: c) How many employees left work? ______ d) Was there a spokesperson for the employees? Yes e) If yes, what is his/her name and telephone number?

No

Name: ____________________________________________ ) Phone: ( 24.

Yes

No

If yes, answer questions a-e:

If yes, answer questions a-e:

a)

a) Name _________________________________________ Mailing Address: Street: _________________________________________ City: ___________________________________________ State: Zip Code: Phone: ( ) -

Provide the following information for the school or educational institution(s).

a) Name _________________________________________ Mailing Address: Street: _________________________________________ City: ___________________________________________ State: Zip Code: Phone: ( ) b)

Are you a substitute teacher for Los Angeles Unified School District (LAUSD)?

b)

No

If yes, answer question 1)

If yes, answer question 1) 1)

Yes

1)

Have you restricted your availability to work with LAUSD?

Yes

No

Dates From: To:

If yes, provide the following dates you restricted your availability and the reason why your availability is restricted.

(mm/dd/yyyy) (mm/dd/yyyy)

Reason: ________________________________________ ________________________________________ ________________________________________ c)

Are you currently in a recess period or off track?

c)

d)

Do you have reasonable assurance to return to work after the recess period or the off track period with any school or educational institution?

d)

e) What is the beginning date of your next recess or the next off track period?

e)

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Yes

No

Yes No If yes, when?

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(mm/dd/yyyy)

(mm/dd/yyyy)

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: 25. Do you expect to return to work for any former employer?

25.

26. Do you have a date to start work with any employer?

26.

If yes, answer question a: a) What date will you start work? 27. Are you a member of a union?

Yes

-

-

No

Yes No If yes, answer question a: (mm/dd/yyyy)

a) 27.

Yes

No

If yes, answer questions a-e:

If yes, answer questions a-e:

a) What is your union name and local number?

a) _______________________________________________

b) Are you in good standing with your union?

b)

Yes

No

c) Does your union look for work for you?

c)

Yes

No

d) Does your union control your hiring?

d)

Yes

No

e) Are you registered with your union as out of work?

e)

Yes

No

28. Are you currently attending, or do you plan on attending school or training?

28.

Yes

No

If yes, answer question a-e:

If yes, answer questions a-e:

a) What is the starting date of the school or training?

a)

(mm/dd/yyyy)

b) What is the ending date of the current session?

b)

(mm/dd/yyyy)

c) What is the name of the school?

c) _______________________________________________

d) What is the telephone number of the school?

d) (

e) What are the days and hours you are attending, or plan to attend, school?

e) Days and hours __________________________________ _______________________________________________

)

- _____________

NOTE: If you completed apprenticeship training, use the space provided above to report the information. Be sure to mail your training certificate with your Continued Claim Form, DE 4581, for the week(s) of training. 29. Are you available for immediate full-time work in your usual occupation?

29.

30.

a) If no, please explain why you are not available for part-time work. 31. Are you currently self-employed, or do you plan to become self-employed? (Self-employment means you have your own business or work as an independent contractor.)

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No

a) Explanation: _____________________________________ _______________________________________________

a) If no, please explain why you are not available for full-time work. 30. Are you available for immediate part-time work in your usual occupation?

Yes

Yes

No

a) Explanation: _____________________________________ _______________________________________________ 31.

Yes

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No

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: 32. Are you now, or have you been in the last 18 months an officer of a corporation or union or the sole or major stockholder of a corporation?

32.

Yes

-

-

No

If yes, answer question a:

If yes, answer question a:

a) Include name of organization and your title or position.

a) _______________________________________________ _______________________________________________

33. Are you currently receiving a pension?

Yes

33.

No

If yes, answer question a:

If yes, answer question a:

a) Are you currently receiving more than one pension?

a)

Yes

No

If yes, proceed to question 35. If no, answer questions b-f:

If yes, proceed to question 35. If no, answer questions b-f: b) What is the name of the pension provider?

b) _______________________________________________

c) Is the pension based on another person’s work or wages?

c)

Yes

No

d) Is the pension a union pension or a pension funded by more than one employer?

d)

Yes

No

e) What is the name of the employer(s) paying into the pension?

e) _______________________________________________ _______________________________________________

f) Did you work for that employer in the last 18 months?

f)

34. Will you receive any additional pension(s) in the next twelve months?

34.

Yes Yes

No No

If yes, answer questions a-b:

If yes, answer questions a-b:

a) What is the name of the pension provider(s)?

a) _______________________________________________ _______________________________________________

b) When will you receive the pension(s)?

b)

35. Are you receiving, or do you expect to receive, Workers’ Compensation? If yes, answer questions a-d:

35.

(mm/dd/yyyy) (mm/dd/yyyy) Yes

No

If yes, answer questions a-d:

a) Who is the insurance carrier?

a) _______________________________________________

b) What is the insurance carrier’s telephone number?

b) (

c) What is the case number, if known?

c) ________________________________________

d) What are the dates of your claim, if known?

d) From:

(mm/dd/yyyy)

To:

(mm/dd/yyyy)

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)

-

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number:

-

36. Have you received or do you expect to receive, any payments from your last employer, other than your regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)

Yes

No

If yes, please provide the information requested in sections A-D.

A.

B.

C.

D.

TYPE OF PAYMENT (Example: vacation pay)

AMOUNT OF PAYMENT (Example: $600)

PAID FROM (Date: mm/dd/yyyy)

PAID TO (Date: mm/dd/yyyy)

37. Are you a U. S. citizen or national?

37.

Yes

No

If no, answer question a:

If no, answer question a:

a) Are you registered with the Bureau of Citizenship and Immigration Services (BCIS, formerly INS) and authorized to work in the United States?

a)

If you are registered with BCIS, answer questions b-e:

If yes, answer questions b-e:

b) What is your Alien Registration Number?

b)

c) What is the expiration date of your work authorization?

c)

d) Were you legally entitled to work in the United States for the last 19 months?

d)

e) What is the title and number of your BCIS document?

e) Check one of the following:

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Yes

No

(mm/dd/yyyy)

Yes

No

Alien Registration Receipt Card (I-151) Resident Alien Card (I-551) Permanent Resident Card (I-551) Employment Authorization Card (I-766) Employment Authorization Card (I-688A) Temporary Resident Card (I-688) Employment Authorized (I-688B) Arrival/Departure Record (I-94) Stamp on Visa (Stamp states: “Processed for I-551 Temporary Evidence of Lawful Admission of Permanent Residence valid until MMDDYYYY, Employment Authorized.”)

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UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: 38. What race or ethnic group do you identify with?

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-

38. Check one of the following: White Hispanic American Indian/Alaskan Native Cambodian Other Pacific Islander Asian Indian Korean Samoan Hawaiian I choose not to answer

39. Do you have a disability? (A disability is a physical or mental impairment that substantially limits one or more life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working.)

-

39.

Yes

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No

Black not Hispanic Asian Chinese Filipino Guamanian Japanese Laotian Vietnamese

I choose not to answer

UNEMPLOYMENT INSURANCE APPLICATION Social Security Number:

-

-

SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D

Please complete the following if you are unemployed or partially unemployed due to a disaster as you may be eligible for DUA benefits: 1.

1.

Are you unemployed as a direct result of a recent disaster in California, such as an earthquake, flood, mudslide, wildfire, etc?

Yes

No

If yes:

If yes, answer questions a-d:

a) Identify the type of disaster.

a) _________________________________________

b) At the time of the disaster, in which county did you reside?

b) _________________________________________

c) At the time of the disaster, in which county did you work?

c) _________________________________________

d) At the time of the disaster, was your unemployment caused by your need to travel through a disaster area?

d)

Yes

No

If yes: Identify the disaster county or counties that prevent travel to your job.

________________________________________ ________________________________________ ________________________________________

e) Check the following that best applies to you:

e)

1) 2)

3) 4)

5) f) If you selected item e1 or e3 above, how many hours did you work prior to the disaster?

f)

g) If you selected e3 or e4 above briefly describe how the disaster affected your ability to continue or begin your self-employment.

g)

h) What is the physical address of your business?

h)

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An employee who is unable to work as a direct result of the disaster. An individual who was scheduled to start work for an employer, but could not because of the disaster. A self-employed individual who is unable to work as a direct result of the disaster. An individual who intended to begin selfemployment, but could not because of the disaster. An individual who became head of household as a result of the disaster.

Street: __________________________________ City: ___________________________________ State: Zip Code:

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DO NOT MAIL OR FAX THIS PAGE

SUBMITTING YOUR APPLICATION Be sure to review your application thoroughly for completeness. An incomplete application may delay or prevent the filing of your claim, or cause benefits to be denied.

Submit your completed application including any applicable attachment(s) by mail or fax: EDD P.O. Box 5007 Buena Park, CA 90622-5007

By MAIL to the following address:

NOTE: Extra postage is required. By FAX to the following telephone number:

1-866-215-9159

Once you submit your application, allow ten days for processing of your claim. You will receive Unemployment Insurance (UI) claim materials by mail. If you have not received any UI claim materials after ten days from the date you submitted your application, call one of the following toll-free telephone numbers: English 1-800-300-5616

Spanish 1-800-326-8937

Mandarin 1-866-303-0706

TTY (Non Voice) 1-800-815-9387

Cantonese 1-800-547-3506

Vietnamese 1-800-547-2058

Date Submitted:

/

/

by

Mail or

Fax

KEEP THIS PAGE FOR YOUR RECORDS

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